Service Charters Establishment of community forums at sub-district
28
Implementation of the school-based management program in Bener Meriah was supported by many different stakeholders,
including:
a.
District Education Office and District Religious Affairs Office. As policy makers, they develop policies
and provide inputs on program implementation. They also monitor and evaluate the program.
b.
Regional facilitators provide training and mentoring
for schools. c.
Bener Meriah Education Concern Forum. This
community forum advocates for local governments and schools to build the capacity of both the service
providers and users so that they could implement the public oriented school-based management.
d.
Teachers and school principals strengthen their
relationships with school committees and community members. They also work together with school
committees to conduct complaint surveys and fulfilled service charters.
e.
Students are one of the complaint survey respondent
groups. They describe the problems they faced at school.
f.
School committees are the schools’ partners in
implementing school-based
management. They
encourage community members to participate in school programs.
g.
Local media help the schools communicate their
programs, problems and improvements to the public.
29
Community members work together to make a garden as a response to complaint
survey results.
Results and Impact
Implementation of the complaint survey as a component of school-based management in Bener Meriah brought concrete
results and impact. The survey has strengthened partnerships between schools and community members, and has clarified
that both are working together to achieve the same goal: better education services.
Improved school transparency and accountability By implementing the complaint survey, Bener Meriah’s schools
demonstrated their good will to improve, and by making their financial reports, work plans, and complaint indexes publicly
available for public, parents and community members can use the documents to oversee the schools’ quality.
Increased public participation With
increased public
participation, schools in Bener Meriah can address
problems related to school facilities
– a problem that many schools cannot solve
themselves due to lack of resources.
The school
committees can
assist schools to repair damaged
classrooms and toilets and to build fences and school
gardens.
30
Improved school responsiveness The public service team and the complaint survey team at
schools were more responsive to public complaints. They discussed the people’s feedback in regular meetings.
These good results have brought positive impacts to education services in Bener Meriah. People now trust schools and
teachers more than before, because they can observe that the schools are trying to be more transparent and accountable.
Furthermore, community members are willing to help schools address problems, and to participate in school programs. In
other words, with public participation, the schools in Bener Meriah have become a model schools, implementing genuine
public service-oriented school-based management.
Monitoring and Evaluation
Implementation of school-based management in Bener Meriah is evaluated by school supervisors on behalf of the District
Education Office. After conducting field visits, the supervisors discuss their findings with the District Education Office,
schools, and other stakeholders. In addition, the Bener Meriah Education Concern Forum holds
quarterly meetings to discuss t
he schools’ progresses in fulfilling their service charters.
Besides external evaluation, school principals are responsible for internal evaluation. They evaluate the school’s programs
with teachers and school committee members.
31
Sustainability
The District Education Office has integrated the school-based management program, particularly complaint survey at schools,
into its work plan and has allocated funds to provide training for schools beyond the original 20 partner schools.
The regional facilitators who assisted schools in implementing school based management are invaluable resources. With their
experience and expertise, they can be recruited by schools and the local government to assist replication and to support
sustainability. The complaint handling mechanisms developed by the schools
will help sustain the program. Using this procedure, schools and community members can identify problems and work together
to seek out solutions. Strong partnerships and open communication between schools and community members
improves people’s trust and increases participation in school programs.
Community forums such as the Bener Meriah Education Concern Forum greatly help program sustainability. They
provide strong channels for community members to support their local governments and schools to improve education
services.
Lessons Learned and Recommendations
1. Initially, it was hard to convince schools to be transparent
and accountable. They had believed that people would demand more from the schools when they knew about the
schools’ plans and reports. To address this issue, the
32
schools were exposed to real examples of the benefits of public participation. The examples came from other schools
that had successfully improved their services thanks to increased community support.
2. The program implementers’ capacity to understand the
program was varied. School principals, teachers, and school committee members had not been able to implement the
school-based management program optimally since they were not exposed to adequate examples. Therefore,
regional facilitators had to be creative when assisting program implementers so that everyone could understand
and play their roles better.
3. Many community members believed that education was the
sole responsibility of government. Although some people did have concerns about education services, they felt that
they could not raise their concerns as there was no forum to do so. To address this problem, the program encouraged
community members to establish forums at district and sub- district level so that they could discuss the educations
issues regularly and seek for the solutions.
4. Complaint handling mechanisms were initially hard to
implement since they were a new concept for many people in Bener Meriah. Therefore, complaint handling mechanisms
were introduced only after careful preparation. Another challenge with regards with the complaint survey was
convincing parents, students, and community members to take part in the survey. Therefore, the complaint survey
team had to use efficient and creative approaches to convince the respondents. Behaviour change activities
33
should be conducted first before beginning the complaint handling introduction.
5. Without channels to pass on complaints, the public will not
participate. Once methods exist, such as community forums, community members will feel more comfortable in
putting forward their concerns and suggestions, and are more likely to actively take part in efforts to improve
education services.
Contact Person
Jailani, S.Pd Head of Program Department
Bener Meriah District Education Office Jl. Seurule Kayu, Kompleks Perkantoran
Bener Meriah, Aceh Telp: 085260663548
Email:
kabid.programbmgmail.com
34
Improving ante-natal
care through
service SOPs
and control cards in Bengkayang,
West Kalimantan
Background
One of the biggest challenges facing Indonesia in its attempt to meet its maternal health targets for the Millennium
Development Goals MDGs is that health care is not even or standardized throughout the archipelago. Health services are
particularly below standard in remote areas far from major cities.
Puskesmas Sungai Raya Kepulauan, a small puskesmas community health center in Bengkayang district, West
Kalimantan Province, serves around 400 pregnant women every year despite limited facilities and staff. The puskesmas and its
village-level birthing clinics have just one ambulance between them, even though their catchment area covers both the
mainland and a large number of islands and river-side communities. Puskesmas Sungai Raya Kepulauan has one doctor
and 12 midwives. Twenty traditional birth attendants TBAs are also active in the sub-district. The puskesmas itself does not
have a delivery room, so women must give birth at the village- level birthing clinics closer to their homes.
Despite its limitations, Puskesmas Sungai Raya Kepulauan has committed to providing a high standard of maternal and child
35
healthcare. In 2012, the center’s doctor and midwives assisted 338 births at facilities or at homes, while TBAs assisted 29
births. No maternal deaths were recorded, but there were two still-births and 12 neonatal deaths.
As with other areas in Indonesia, the ante-natal services provided by Puskesmas Sungai Raya Kepulauan vary from facility
to facility. No standards are followed, so the quality varies significantly. To overcome this challenge and to standardize
ante-natal care, Kinerja assisted the puskesmas to develop and implement standard operating procedures for ante-natal care
SOP ANC. The SOP focused less on the details of medical procedures and more on the manner of services required to be
given, as it was assumed that all medical staff have been trained in carrying out the required tasks.
The staff of Puskesmas Sungai Raya Kepulauan.
36
Program Innovation
Public service provision, including health service provision, must be able to be relied upon. One way of ensuring consistency and
reliability is to implement standard operating procedures SOPs.
SOPs are documents with written instructions on how to carry out an activity, when to carry it out, where to do so, and who
is responsible for doing so. By standardizing a process in this way, SOPs ensure that the same tasks will always be carried
out in the same way, even if they are performed by different people, at different times, and in different places. This means
that activities should always meet the same standard. SOPs are very useful tools for organizational activities that are
routine or occur frequently. The consistent implementation of SOPs means that comprehensive guidelines for all activities
exist, and that there is no reason for deviation. This makes organizations more accountable and reliable, and there is less
chance of mistakes being made
– something that is particularly crucial in health care.
SOPs act as guides for health workers. They are based on medical and scientific knowledge, and are developed in line with
national standards for health care. They must be mandatory with regards to implementation. SOPs also assist with
monitoring and evaluation, as they provide a benchmark for what should be done.
SOPs are mandated by the Indonesian government through Law no. 252009 on Public Service Delivery. All public service
providers are required to develop service delivery standards
37
that are non-discriminatory, respect diversity, and prioritize community consensus.
The service SOPs that Kinerja supported the development of are similar to medical SOPs, but instead of providing
information on medical procedures, they guide workers on service provision and administrative processes.
Kinerja assisted Puskesmas Sungai Raya Kepulauan by developing a number of service SOPs relating to ante-natal
care. They include:
- Service standards for ante-natal care ten services, known as ‘10T’ in Indonesian, which include measuring
the moth er’s nutritional status, measuring uterine
height, measuring blood pressure, measuring iron levels, providing iron tablets, and vaccinating for tetanus
toxoid
- Service flowchart for ante-natal care indicating where a patient should go and in what order, e.g. midwife first,
then laboratory, then pharmacy - Referral mechanism for obstetric and neonatal
emergencies - Service fee list
- Waiting time standards. The puskesmas
also made a ‘control card’ that serves as a monitoring tool to analyze whether staff are following the ante-
natal care procedures. The control cards are made up of three sections: the first is a list of the ten services a woman should
receive during ante-natal care; the second is a box for feedback; and the third contains information on nutrition for mothers and
babies, safe delivery, and immediate and exclusive breastfeeding.
38
Half the control card is taken home, while half is
put into the suggestion box for follow-up by the
puskesmas. All SOPs were developed
jointly by administrative and medical staff at the
puskesmas,
and were
socialized to all staff after being signed by the head
of the center. In order to ensure compliancy and to build patients’ knowledge on their
rights to healthcare, the puskesmas displayed the SOPs on the walls and doors of both the waiting room and the ante-natal
care room. The control cards are also given to all women visiting for ante-natal care upon registration with the front
desk.
Implementation Process
1.
Mapping existing SOPs and service standards. Before
developing new SOPs – whether medical or service SOPs –
existing SOPs and service standards at the puskesmas and District Health Office DHO need to be mapped and
analyzed. The staff of Puskesmas Sungai Raya Kepulauan compiled all of their SOPs and standards, and evaluated
whether they met national standards and whether they were properly implemented.
The control card used for measuring ante- natal care services introduced at Puskesmas
Sungai Raya Kepulauan.
39
2.
Mapping SOPs and service standards that should be implemented. The puskesmas staff and the local multi-
stakeholder forum MSF – a type of community forum for
public service oversight – came together to discuss the
services delivered by the puskesmas. They identified which services did not yet have SOPs or did not have SOPs in line
with national standards. One of these was ante-natal care –
although the puskesmas had already developed an SOP for ANC, it did not state the amount of time procedures
should take nor the costs for such services.
3.
Drafting of new SOPs. All new SOPs were developed in
a participatory and transparent fashion. Unlike the traditional top-down method where the head of the
puskesmas or the head midwife drafts the SOPs, at Puskesmas Sungai Raya Kepulauan, all staff and MSF
members were invited to take part. This ensured that all stakeholders felt involved and listened to, and that all could
fully commit to implementing the new SOPs.
4.
Socialization of new SOPs. After being drafted and
agreed upon, all SOPs were socialized to all staff and were trialed before being officially implemented. It is vital that all
staff have a strong understanding of what each SOP contains and what services it guarantees to give patients. Without
proper socialization, staff may ignore the new SOPs and not implement them.
5.
Transparent publishing of SOPs. All new SOPs were
printed and displayed on the walls and doors of the puskesmas. This transparency increases the trust of the
community towards health workers and improves the
40
quality of the services they receive for two reasons – one,
because health workers are constantly reminded of what they should do, and two, because patients are aware of
what they should receive. The ’ten steps’ of ante-natal care SOP is displayed in the ANC Room and on its door, along
with the service flowchart, waiting times, and referral mechanism. The list of service costs is displayed in the
waiting room. Displaying these SOPs in these locations gives pregnant women the greatest amount of time to read and
understand the types of ante-natal care they should receive at the puskesmas.
6.
Implementation, display, and socialization of SOPs to all public health facilities in the sub-district. After
trialing and implementing the new SOPs at the puskesmas, the staff ensured that all other public health facilities under
their management also implemented and displayed the SOPs. This included at village-level birthing clinics polindes
and poskesdes and monthly mother-and-baby sessions at the integrated health posts posyandu. This was done to
ensure that ante-natal care quality did not vary from one facility to another. The list of fees for services and the new
referral mechanism were also displayed at all facilities to make sure that the information reached all residents.
7.
Routine re-socialization of SOPs. To ensure
compliance with SOPs, routine re-socialization to staff is necessary. The staff should then continue this by reminding
the community of the standards of services they should receive. This is important to make sure that SOPs are not
forgotten or ignored.
41
8.
Development of ANC control card for monitoring SOP compliance. Puskesmas Sungai Raya Kepulauan was
the first puskesmas to implement Kinerja’s ANC control
card. The card includes information for patients on the ANC services they should receive, offers a section for
feedback, and provides information on maternal health, nutrition, and breastfeeding. The cards are printed on
ordinary white A4 paper and cut to make two cards per sheet. At Puskesmas Sungai Raya Kepulauan, 500 cards are
enough for all pregnant women for one year.
Results and impact
The biggest impact of implementing SOPs and the control card for ante-natal care at Puskesmas Sungai Raya Kepulauan was the
standardization of services across all public health facilities in the sub-district. Now, pregnant women can receive the same
quality of service whether she goes to the puskesmas or to a village-level birthing clinic, because all have implemented clear
SOPs on ante-natal care. Since introducing service SOPs, the number of patient
complaints regarding costs and waiting times have dramatically reduced. The staff see this as a result of displaying standard fees
and waiting times in the waiting room. The other impact has been an increase in the number of
women coming to facilities for ante-natal care and childbirth. A marked increase occurred between 2012, when service SOPs
were introduced, and 2013. The staff at the puskesmas explain this as a result of women now knowing more about the
services they should receive, which has resulted in higher levels
42
of trust. The clarity with which services are outlined in the SOPs means that women feel more comfortable in coming to
the puskesmas and other facilities, as they know exactly what will happen, who will perform it, how much it will cost, and
when they can receive the service. Related to the increase in facility-based births is that immediate
breastfeeding rates have more than doubled between 2012 and 2013. This is because all midwives are now required to perform
immediate breastfeeding for births both at facilities and at homes. Midwives also assist in performing the procedure when
called by TBAs or families to assist with deliveries, even if they arrive too late to assist the birth itself. This has also had a small
impact 13 increase on exclusive breastfeeding rates. Neonatal deaths have also decreased by more than 40.
Maternal health statistics for Sungai Raya Kepulauan sub- district, Bengkayang 2012-2013
Births assisted
by trained
medical workers
Births assisted
by TBAs
Immediate breast-
feeding Exclusive
breast- feeding
Neonatal deaths
2012 338
29 208
77 14
2013 418
24 451
87 8
Monitoring and evaluation
Although Puskesmas
Sungai Raya
Kepulauan began
implementing its SOPs in late 2012 and early 2013, it did not develop the ANC control card until 2014 when the staff
realized they needed a better method of monitoring compliance.
43
The control card enables the puskesmas to explore what services are being provide, and if they are not, why not. All
ANC patients return half of their control cards to the puskesmas after their check-ups; the patients keep the other
half. As the control cards list the ten services all pregnant women are supposed to receive, the staff can examine the
services one by one. For example, if multiple cards indicate that the patient did not receive iron tablets which all patients
should receive, the staff will investigate the issue and find out why: was it because the women did not want the tablets? Was
it because there are no tablets in stock? Was it because the midwife did not offer them? After identifying the problem, the
staff can then work to find a solution.
Challenges
At the beginning, many staff at Puskesmas Sungai Raya Kepulauan lacked knowledge of SOPs. Not only were they not
aware of how to develop medical and service SOPs, staff did also not know about the importance of having SOPs and
standardized services. This meant that Kinerja spent some months raising the knowledge and understanding of puskesmas
staff first, before beginning to examine existing SOPs and drafting new ones.
Another significant challenge that became obvious during the assistance period was that there was confusion over the
different between medical SOPs and service SOPs. Medical SOPs contain the steps required to carry out medical
procedures on patients, whereas service SOPs cover how the non-medical aspects of services are implemented. For example,
44
an SOP on childbirth is a medical SOP, while an SOP on complaint handling is a service SOP. This issue emerged a
number of times, especially when new staff began working at the puskesmas and had never encountered service SOPs before.
Transparency was also an issue. Many SOPs, both medical and service, had been developed over the years. However, few
were displayed for staff andor public consumption
– the vast majority were simply stored in drawers or cupboards and
never looked at. This meant that SOPs largely went unimplemented and unfollowed, and that staff did not
understand why SOPs should be displayed on walls or doors. This was especially the case amongst medical staff, some of
whom believed that SOPs were private documents that should not be available to the community.
A service SOP for ante-natal care on display on the door of the MCH room at Puskesmas Sungai Raya
Kepulauan.
45
Sustainability
The implementation of SOPs on ante-natal care will be sustainable at Puskesmas Sungai Raya Kepulauan if they are
regularly monitored. Without monitoring, they are likely to disappear off the walls and end up in drawers and cupboards
once more, unimplemented. The display of and compliance towards SOPs should be monitored not just by the head of the
puskesmas and the head midwife, but also by the community. All people are entitled to have oversight over implementation.
If staff or community members see a member of staff not following an SOP, they should report it to the head of the
puskesmas or the head midwife to ensure it does not happen again. This means that SOPs should be regarded as living
documents that can be altered based on feedback, monitoring and evaluation, and new developments in technology and
policies. Cost-wise, SOPs do not require any finance upkeep. Control
cards can be printed andor photo-copied once a year for a small fee.
The DHO of Bengkayang has stated that they will replicate SOPs for ANC to all puskesmas in the district in 2015.
Lessons learned and recommendations
Puskesmas Sungai Raya Kepulauan is now regarded by the Bengkayang DHO as one of the district’s most innovative
puskesmas in terms of maternal and child health. Puskesmas Sungai Raya Kepulauan’s experience proves that
service SOPs on ante-natal care can have a significant and
46
immediate effect on the quality of care. By following standard procedures and meeting national standards, the puskesmas and
its staff can show patients that they are providing appropriate care that is as good as at any other puskesmas elsewhere in the
country. Service SOPs are most effective when they are developed and
implemented in a participatory and transparent manner. Community representatives should be involved in the design
and monitoring processes, as should all puskesmas staff. Service SOPs should also be displayed in public on the walls and doors
of health facilities, to ensure compliance from staff and to build public awareness of the rights to quality health care.
Both medical and service SOPs should ideally be standardized across the country, with allowances for local variations and
add-on services such as HIV testing and urine testing for puskesmas with appropriate laboratory facilities, and
ultrasounds for facilities with USG machines. Doing so will reduce the chance of non-compliance to standard care
procedures, and will ensure that all mothers and babies receive the same services.
Contact details Mahlil Ruby
Former Health Specialist, Kinerja USAID drmahlilhotmail.com
Kate Walton Knowledge Management and Training Specialist, Kinerja USAID
kwaltonkinerja.or.id katewalton.augmail.com
47
Improving health service quality through service charters
Background
Probolinggo District in East Java covers a population of more than one million people living across a large area. This means
there is a high demand for healthcare. The District has 33 puskesmas, including 19 which provide in-patient facilities.
One of these is Puskesmas Sumberasih. Despite being one of the best puskesmas in the district, Puskesmas Sumberasih still
witnesses multiple maternal and neonatal deaths every year. Before the puskesmas began working with Kinerja, field data
revealed numerous issues: partnerships between midwives and traditional birth attendants did not run smoothly; standard
operating procedures SOPs on pregnancy, delivery and neonatal care had not been developed; no complaint surveys
had ever been carried out; waiting times averaged over 30 minutes; formula milk was commonly promoted at health
facilities; no staff member was tasked with overseeing the daily running of healthcare; and there was no public joint
commitment from the management and the staff to provide the best health services possible.
Puskesmas Sumberasih serves around 1,000 pregnant women every year. This led to the management agreeing to work with
Kinerja to improve their maternal and child health MCH services to ensure that mothers and babies made it through
pregnancy and delivery safely.
48
Program Innovation
In order to improve the quality of its MCH services, Puskesmas Sumberasih decided to focus on improving its management.
This was because the medical care provided by the puskesmas was deemed to already be sufficient, with the problems
experienced at the facility originating more from administrative and operational processes.
The puskesmas undertook the following activities: 1.
Developing SOPs for both medical and service
procedures relating to MCH. 2.
Implementing a complaint survey to show that the
puskesmas was open to changing and receiving feedback from patients and the broader community.
3.
Informal relationship building between traditional birth attendants and puskesmas medical staff, led by
the head of the puskesmas. 4.
Introducing a ban on formula milk in the sub-district’s
health facilities and at private midwifery clinics, and providing breastfeeding equipment such as breastmilk
pumps and fridges for storage at the puskesmas.
5.
Establishment of a Manager on Duty position to
oversee the daily provision of services, including ensuring that staff arrive and leave on time, that staff are providing
services in line with SOPs, and that patients are able to pass on any complaints or suggestions.
6.
Provision of nutrient-rich plants to pregnant mothers after attending ante-natal check-ups,
particularly after the first and second trimester check-ups. Mothers were given daun katuk and daun kelor plants, which
are both highly nutritious and promote breastfeeding.
49
7.
Carrying out a complaint survey and developing a service charter containing agreed improvements that
need to be made, along with technical recommendations for the District Health Office DHO.
For Puskesmas Sumberasih, one of the most meaningful activities they conducted was the complaint survey and its
resulting service charter. All 61 of Kinerja’s partner puskesmas throughout Indonesia, including Puskesmas Sumberasih, were
required to develop service charters as a way of involving the community in improving service quality. Service charters were
developed following a complaint survey, in which a structured questionnaire was used to gather complaints and feedback from
service users. The survey was carried out by members of the local sub-district multi-stakeholder forum MSF, which is made
up of community members. The complaints fielded during the survey were ranked in a complaint index by the quantity of
responses to certain issues. The complaints were then discussed in a number of FGDs, and
solutions were put forward by both community members and puskesmas staff. Once solutions were agreed upon, the
puskesmas drafted a service charter which outline the problems that could be solved internally by the puskesmas itself. For
external problems, which required the assistance of the local government, a list of technical recommendations was given to
the DHO. Both were signed by the head of the puskesmas. The service charter was printed as a standing banner and displayed
in the puskesmas waiting room so that it was visible to all patients.
50
Service charters are a useful way to increase meaningful civic engagement in public service delivery. They help to ensure that
services are accountable and transparent, and that providers are responsive to service users’ needs. Puskesmas Sumberasih
worked on fulfilling its service charter promises over the 12 months following its development; the banner was displayed
throughout this entire period.
Implementation Process
1.
Initial meeting between puskesmas and Kinerja’s implementing
organization ,
the Children’s
Protection Organization Lembaga Perlindungan Anak
– LPA. LPA met with the head of Puskesmas
S umberasih to discuss both Kinerja’s and the puskesmas’
aims and hopes. The head of Puskesmas Sumberasih stated that community members have the right to participate in
public service improvement efforts, and that he was interested in exploring how community complaints could
help.
2.
Changing ideas of what complaints mean. The head
of Puskesmas Sumberasih knew his staff were reluctant to deal with community complaints, as they felt as though they
were simply being criticized. He worked hard to convince his staff that complaints were actually a source of
information that could help them improve their services, and that one way of accessing this was through a complaint
survey.
3.
Establishment of a multi-stakeholder forum MSF.
With Kinerja’s assistance, Puskesmas Sumberasih
51
established a sub-district MSF in November 2012 that aimed to oversee, mediate, coordinate, and advocate for
improvements in public health care. MSF members included community leaders, religious leaders and traditional cultural
leaders, as well as government staff and CSO members. To open the door to increased public participation, one of the
first activities the MSF carried out was the complaint survey.
4.
Workshop on complaint handling and questionnaire development. As the first step in the complaint survey,
the puskesmas and the MSF jointly held a complaint workshop consisting of 80 service users and 20 service
providers. The workshop identified complaints regarding services at the puskesmas, and a list of complaints was
drafted. This list became the basis of the questionnaire.
5.
Complaint survey. In January 2013, Puskesmas
Sumberasih’s MSF carried out the complaint survey by interviewing 140 users of MCH services. All respondents
were pregnant mothers or mothers with children under two years of age.
6.
Complaint index. The results of the complaint survey
were ranked by frequency of response and were listed in the form of a complaint index.
7.
Complaint survey analysis workshops. The complaint
index was jointly analyzed by MSF members, community representatives, and puskesmas staff at a series of
workshops that aimed to identify the root causes of complaints.
52
8.
Drafting and signing of service charter and technical recommendations. Two types of issues were identified
– internal problems that could be solved internally by the
puskesmas itself, and external problems that required the help of the local government. Internal problems and their
solutions were then compiled into a service charter; external problems and their solutions were written up as
technical recommendations to be given to the DHO. Both documents were signed by the head of Puskesmas
Sumberasih at a public event witnessed by DHO, Bappeda, the MSF, and the community. This was done in an effort to
support transparency. The technical recommendations were handed to the DHO while the service charter was
printed as a standing banner and displayed in the puskesmas waiting room until all complaints had been sufficiently dealt
with.
9.
Monitoring of service charter and technical recommendations. The local MSF was responsible for
monitoring the implementation of both service charter and technical recommendations. The MSF carried out regular
checks to see whether improvements had been made and promises had been fulfilled. The heads of the puskesmas and
DHO were informed of monitoring results and reminded to overcome complaints that had not yet been solved.
10.
Repeat of complaint survey. Puskesmas Sumberasih
was so pleased with how the complaint survey helped identify problems and improve services that at the time of
writing, they were planning to repeat the process and make complaint surveys a regular part of their programs.
53
Results and impact
Puskesmas Sumberasih and its MSF agree that a number of significant improvements have taken place since the complaint
survey was carried out. Previously, the puskesmas felt as though it was solely
responsible for making improvements and overcoming any problems that occurred. The community also felt that all issues
about health care were the responsibility of the puskesmas alone. Since the complaint survey, the community’s feelings of
ownership and trust have increased, and the puskesmas frequently involves the MSF in meetings and workshops.
There has been a measurable increase in the number of pregnant women seeking the services of Puskesmas Sumberasih
since the puskesmas began actively working to improve its management of MCH services. The table below illustrates how
these numbers have grown since 2011, the year before Kinerja began assisting Puskesmas Sumberasih. After two years of
support, the number of deliveries assisted by medical professionals rose 6, first ante-natal check-ups by 13, and
fourth ante-natal check-ups by 7. This indicates that more women trusted the puskesmas to provide them with high-
quality MCH services.
MCH services at Puskesmas Sumberasih, Probolinggo 2011
2012 2013
Deliveries assisted
by medical professionals
926 963
979
First ante-natal check-up 1,125
1,181 1,268
Fourth ante-natal check-up 860
848 918
54
This increase is also due to the number of new partnerships between midwives and traditional birth attendants TBAs. In
2011, 128 TBAs had not yet joined into partnerships with midwives; by 2014, just 8 TBAs remained un-partnered. These
partnerships require TBAs to no longer assist deliveries by themselves but to instead refer pregnant and delivering women
to the puskesmas where they can be assisted by midwives. As community members trust TBAs, they then come to trust the
puskesmas and its midwives. In terms of puskesmas administration and how services are
provided, the biggest impact has occurred as a result of installing a fingerprint registration system for patients. During
the complaint survey, 85 respondents complained that waiting times were too long over 30 minutes on average and that part
of this problem was that the registration process took too long. The MSF and the puskesmas discussed this issue, and agreed to
trial a fingerprint registration system that automatically links patients’ medical files with their fingerprints. Registering for an
appointment now only takes a few seconds; previously, it took more than three minutes per patient. The system works even if
patients have left their ID or insurance cards at home. Although it seems like only a small difference, it must be remembered
that the puskesmas serves more than 100 patients a day
– a saving of 2.5 minutes per patient means the system can flow
much more smoothly and efficiently. The head of Puskesmas Sumberasih, Hariawan Dwi Tamtomo,
said the fingerprint registration system was a direct result of the complaint survey results. “We found out that many patients
complained about having to wait a long time. We’ve been using
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a digital medical file system, SIMPUSTRONIK, since 2007, so we added the fingerprint registration syst
em,” he said.
Since working to improve its management and administrative systems, Puskesmas Sumberasih has won a number of awards.
In 2012, it won the awards for Cleanest In-Patient Facilities and Best Performance of all puskesmas in Probolinggo district. In
2014, Puskesmas Sumberasih was ranked by the Provincial Health Office as the Second-Best Puskesmas in all of East Java.
Monitoring and evaluation
Monitoring and evaluation is a joint activity at Puskesmas Sumberasih, carried out by DHO, MSF, and puskesmas staff
themselves. In terms of the service charter and technical recommendations, the MSF monitored its implementation once
during the twelve months after the complaint survey. MSF members checked whether improvements had taken place, and
The fingerprint registration system in operation at Puskesmas Sumberasih.
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reminded the puskesmas and the DHO to follow-up if no improvements had occurred. When the puskesmas decided to
run a second complaint survey, the MSF ensured that previous complaints that had not yet been dealt with were also part of
the new questionnaire. Monitoring at Puskesmas Sumberasih also takes place through
complaint handling mechanisms. If any complaints are received by the puskesmas, the staff discuss them and find solutions for
them with MSF members at a regular mini-workshop. The Probolinggo DHO also carries out regular monitoring and
evaluation of Puskesmas Sumberasih, as it does for all puskesmas in the district.
Challenges
When first training puskesmas staff on the complaint survey process, Kinerja and its IOs received some initial resistance
towards the idea. Many staff members – medical professionals
and administrative staff alike – were of the opinion that
criticism of the puskesmas from the community would give the facility a bad reputation. Fortunately, the head of the Puskesmas
believed that complaints would actually help the centre improve, and worked with the MSF to convince his staff
members to give the complaint survey method a try. The head explained that criticism helps him and his staff identify what
problems exist and what community needs are going unmet. The community also had some reservation towards the
complaint survey at first. Service users were worried that if they complained about the puskesmas and its services, they
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would later receive sub-standard health care. The community slowly began to shift their perceptions after the puskesmas
explained that they were genuinely open to community feedback and promised that whatever was said would not have
a negative impact on the services they provide to patients. The other main challenge was that Puskesmas Sumberasih had
never carried out a complaint survey before, so they did not know how to do so. Kinerja’s IO, LPA, trained both puskesmas
staff and MSF members on the process and its implementation, and incorporated complaint surveys, service charters, and
technical recommendations from other districts as examples.
Sustainability
The high level of public participation and oversight at Puskesmas Sumberasih, as demonstrated by the local MSF,
means that there is a strong likelihood that the changes achieved will be sustained. Sumberasih’s MSF has been
consistently active in the two years since its establishment, and its members are still enthusiastic and interested to continue
their work. The Puskesmas itself has stated its commitment to civic
engagement, and has begun to involve the public in more of its regular management and administrative activities, such as
planning, budgeting, and monitoring. The head of the Puskesmas is keen to continue working with the MSF.
Kinerja and its IOs have supported more than 100 puskesmas throughout Indonesia to carry out complaint surveys since
2012. Local governments have begun replicating the process at
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other puskesmas since seeing the impact it has had on pilot puskesmas, while many puskesmas who have already run the
complaint survey once are interested in repeating the activity. On average, 80 of complaints put forward during the survey
have been dealt with at Kinerja’s original 61 partner puskesmas.
Lessons learned and recommendations
Puskesmas Sumberasih ’s experience in carrying out a complaint
survey and implementing a service charter has shown that co- operation between community members and health facilities
has a positive impact on the quality of public service delivery. Problems are not only more easily identified but also more
easily solved. The key lessons can be summarized as follows:
- A service charter and list of technical recommendations
become a bridge to improved transparency and accountability because they are based on not what the
puskesmas thinks the community needs, but on what the community thinks the community needs.
- Technology can be an effective way of speeding up services and increasing efficiency. Technology such as fingerprint
registration is also simple to use and makes life easier for patients, as they no longer need to bring their ID and
insurance cards.
- Having a manager on duty to oversee daily activities at the puskesmas is an effective way of ensuring SOPs are followed
and that patient needs are met. - Personal and informal advocacy from key figures, such the
head of the puskesmas, can change long-held attitudes and mindsets.
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Over 100 puskesmas throughout Indonesia have now undertaken the complaint survey process and developed
service charters. In general, puskesmas who have made improvements based on service charters are cleaner and in
better condition in terms of infrastructure; are served by friendlier, more polite staff; provide services in line with
national standards; deliver more babies; carry out more ante- natal check-ups; and support more mothers to immediately and
exclusively breastfeed their babies. Most importantly, both staff and patients are more satisfied with puskesmas services, and
health outcomes are starting to improve.
Contact details Dr Hariawan Dwi Tamtama
Head of Puskesmas Sumberasih +62 335 427268
Lily Pulu Former Public Service Oversight Specialist, Kinerja USAID
lily.pulugmail.com
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Improving promotion
of immediate
and exclusive
breastfeeding
Background
Exclusive breastfeeding is when babies are fed only breastmilk for the first six months of their lives, and receive a combination
of breastmilk and other foods until the age of two years. Exclusive breastfeeding has been proven to improve the
nutritional status of babies and strengthen immune systems. Levels of exclusive breastfeeding are low in Indonesia.
According to national data from 2012, only 33.6 of babies under two are breastfed by their mothers. This is influenced by
low levels of understanding about breastfeeding in addition to local cultural beliefs and misconceptions. Many mothers believe
that breastmilk does not provide adequate nutrition for their babies, so they give them additional food and drink such as
honey, coconut water, and over-cooked rice even though they are under six months of age. A high proportion of mothers also
choose to give formula milk rather than breastmilk because it is considered to be better for babies’ growth, more modern, and
healthier. In some parts of Indonesia, mothers also believe that colostrum the first breastmilk is dangerous for babies and
must be disposed of, which leads to a reliance on formula milk during the very important first few days of life. Some mothers
avoid breastfeeding because of the belief that it will cause their breasts to droop and sag. Many are also embarrassed to
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breastfeed in public, or simply find using formula and a bottle easier.
Other factors also come into play. In Indonesia, one key influencer is the formula milk industry, which carries out
intense advertising and promotion of its products. Following bans on advertising formula milk for babies under the age of
two on TV and in print, formula milk producers instead have widely entered into partnerships with health facilities and
midwives, offering prizes and rewards for those who promote and sell formula milk. It is common to see formula milk logos
and slogans on medical products and products for new mothers, and many midwives have side businesses in selling
formula milk. This issue is compounded by the lack of promotion on immediate and exclusive breastfeeding from
health facilities and district health offices DHOs, although the situation has begun to change in the last few years.
On paper, some community health centers puskesmas have plans to promote immediate and exclusive breastfeeding, but
many do not. Unfortunately, even amongst puskesmas who do carry out breastfeeding promotion, activities are generally
limited in scope and have minor impact. In an attempt to improve the quality and impact of such activities, Kinerja
worked with puskesmas to make their breastfeeding promotion more relevant, more interesting, and more participatory.
Some of the most interesting approaches to breastfeeding promotion occurred in Bener Meriah in Aceh, in Tulungagung
and Probolinggo in East Java, and in Makassar in South Sulawesi. In 2010, exclusive breastfeeding was low in all four of these
districts. In Bener Meriah, just 40 of children under the age of
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two were exclusively breastfed. In Tulungagung, the rate was 52.5; in Probolinggo, 34; and in Makassar, 59. Kinerja’s aim
was to improve the awareness of the importance of immediate and exclusive breastfeeding, with the longer-term goal of
improving breastfeeding rates.
Program Innovation Each Kinerja partner district that worked on improving
breastfeeding promotion developed its own approach, designed to be effective in the local cultural context.
Co-operation between the Office of Religious Affairs and puskesmas: Bener Meriah, Aceh
A long-held myth in Bener Meriah is that breastmilk contains bacteria that are dangerous for babies. Called dena in the local
language, this myth is so wide-spread that the majority of mothers in the district give their babies formula milk, with
some also using the water in which rice is cooked as an additional drink.
This myth also means that many new mothers refuse to carry out immediate breastfeeding, despite the advice of midwives.
Colostrum is considered to be ‘bad milk’ that has gone stale, so is generally not given to babies.
Local knowledge of the importance of exclusive breastfeeding is also low, as many midwives and doctors do not explain this to
pregnant women and their families. Unfortunately, this has led to weakened immune systems amongst babies. Diarrheal
illnesses are also common due to a lack of clean water available for mixing formula milk.
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Bener Meriah decided to attempt to improve rates of immediate and exclusive breastfeeding by including information
on these topics in the pre-marital courses run by the local Office of Religious Affairs. All couples intending to marry are
required to attend these courses, and since 2013, health professionals such as the head of puskesmas and the head
midwife have been included in the courses to give information on breastfeeding and safe childbirth. Crucially, the Office of
Religious Affairs provides religious justification for breastfeeding in the form of a fiqh booklet containing religious law that
supports breastfeeding. The booklet was developed in coordination with the District Ulama Council, the Islamic Law
Office, the District Health Office, puskesmas, and local religious and community leaders.
All couples intending to marry must participate in the one- week pre-marital course before their wedding. On average,
Bener Meriah holds five or six courses every year. Couples receive information on maternal and child health, preparing for
childbirth, the delivery process, and immediate and exclusive breastfeeding. All couples are given a copy of the fiqh booklet.
The booklets are also available to read at the puskesmas. Formula Milk Ban: Puskesmas Beji, Tulungagung, East Java
Puskesmas Beji, one of Kinerja’s partner puskesmas in Tulungagung district, East Java, took the brave decision in May
2013 to ban all formula milk promotion and sale in their catchment area. The puskesmas ended its partnership with a
formula milk producer and stopped offering products at both the puskesmas itself and the numerous village-level birthing
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clinics. Staff are also forbidden to become promoters or salespeople for formula milk products.
The decision was made by the head of the puskesmas following demands from community oversight bodies. It was also in line
with a new district regulation that forbids the promotion and sale of formula milk in health facilities.
In order to support the ban, the puskesmas stepped up its efforts to promote immediate and exclusive breastfeeding. The
staff began new community education programs which aimed to overcome two key local misconceptions: that babies only cried
because they were hungry, and that formula milk is the best food for babies.
Integrated Breastfeeding Campaign: Probolinggo, East Java The government of Probolinggo district in East Java are strong
supporters of immediate and exclusive breastfeeding because of
Breastfeeding mothers say Breastmilk is the best at Puskesmas Beji, Tulungagung.
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the huge nutritional and immune benefits they provide to babies. Since beginning its work with Kinerja, the district
government has so far developed a district head regulation that supports breastfeeding and safe childbirth; sponsored
community festivals and healthy food competitions; elected breastfeeding ambassadors; and provided training to religious
figures on how to support breastfeeding and why they should do so.
One high impact activity the government of Probolinggo did was to elect the District Head, Hj. P. Tantriana Sari, as a
breastfeeding ambassador in 2014. As both the elected leader of the district and a mother herself, the District Head can play
an important role in convincing families on the importance of breastfeeding. Ms Tantri, as she is commonly called, even made
a commitment to continue breastfeeding her young child while working as District Head. She also issued a decree that
instructed all work places and public places to establish breastfeeding rooms and that forbade health facilities and
private midwives from selling formula milk. Ms Tantri also regularly drops in at puskesmas unannounced to ensure they
are not promoting or selling formula milk products. A number of government buildings have already followed the decree and
have set up breastfeeding rooms, including at the district parliament, the district health office, two hospitals, and seven
puskesmas. With the clear and active support of the District Head, the
people of Probolinggo can see that the government is truly committed
to supporting
immediate and
exclusive breastfeeding. Mothers report feeling strengthened in their
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decisions to breastfeed, and as though they are able to do so without worrying about discrimination or stigma.
The community has also been active in supporting breastfeeding mothers. Twenty-two sub-districts have each formed
Breastfeeding Support Groups. Consisting of mothers and community members concerned about low breastfeeding rates,
the groups meet regularly to discuss challenges and successes, and to share information about breastfeeding and child health.
One of the most creative breastfeeding promotion activities has been carried out by the district’s puskesmas – the planting of
katuk and kelor plants. Both are locally-grown but not widely- consumed, despite their nutritional value, as are often viewed
as ‘poor people’s food’. Katuk sauropus androgynous is a leafy plant which, if consumed, is believed to encourage the
production of breastmilk. Kelor moringa oleifera, on the other hand, is a nutritious leafy plant which contains high levels of
Vitamins A, B2, B6 and C, iron, and magnesium. A District Head Decree has instructed all health facilities to develop and
maintain small gardens that include both katuk and kelor plants, and to prepare meals for new mothers made of these leaves.
Some puskesmas also give out seedlings of katuk and kelor to expecting mothers as an incentive to attend ante-natal check-
ups. Our Community Cares about Breastfeeding: Makassar,
South Sulawesi Although there are now numerous breastfeeding movements
throughout Indonesia, the majority are dominated by women. Few men tend to be involved. This is because breastfeeding is
considered to be a ‘women’s issue’.
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With Kinerja’s assistance, the city of Makassar in South Sulawesi has carried out a wide-reaching breastfeeding
awareness raising campaign directed at men. It aims to encourage men to become advocators for and supporters of
breastfeeding. The campaign began by attempting to change the idea that breastfeeding is only something women should care
about, by establishing groups called Fathers Who Care about Breastfeeding. The groups’ members are made up of
professors, public servants, religious leaders, community leaders, neighborhood heads, and other community members.
The groups aim to increase the rates of immediate and exclusive breastfeeding through making men aware that their
children’s health is not just their wife’s responsibility but theirs as well.
I augurati g the it ’s e E lusi e Breastfeedi g A assadors i
Makassar, South Sulawesi, in 2013.
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The Fathers Who Care about Breastfeeding groups run education activities at the sub-district and neighborhood levels.
They provide advice to new mothers and fathers on exclusive breastfeeding, and promote its nutritional benefits over formula
milk. The groups’ members are also now often involved in discussions, workshops and trainings on breastfeeding as
facilitators and presenters. In 2014, the groups worked with the city’s Multi-Stakeholder
Forums MSFs
– community forums established by the Kinerja program to oversee public service provision to develop a peer
learning module for breastfeeding supporters. The module was designed to increase the knowledge and understanding of
supporters on immediate and exclusive breastfeeding, and to improve their capacity to provide support and advice to families
encountering breastfeeding problems.
Implementation Process Co-operation between the Office of Religious Affairs and
puskesmas: Bener Meriah, Aceh Bener Meriah’s District Health Office DHO realized that one
of the biggest factors behind low breastfeeding rates in their district was the persistence of the dena myth, which claims that
breastmilk contains bad bacteria. The DHO began a series of discussions with local partners, such as puskesmas, the Office of
Religious Affairs, the Islamic Law Office, and others, talking about what could be done to eradicate the myth. The
stakeholders agreed to develop a program to overcome the misconception.
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One of the recommendations that came out of the discussions was to develop a partnership between the Office of Religious
Affairs and the district’s puskesmas in order to promote good
maternal and child health to couples about to be married. This was considered a strategic way of reaching key communities, as
both men and women have to attend pre-marital courses run by the Office of Religious Affairs. A Memorandum of
Understanding MOU was developed between the Office of Religious Affairs and Bener Meriah’s puskesmas to run pre-
marital courses that include information on safe delivery and immediate exclusive breastfeeding in addition to the regular
material provided. Following the signing of the MOU, staff from the Office of
Religious Affairs were trained by staff from the DHO and puskesmas on safe childbirth and breastfeeding. These staff
were required to share their new learning with other staff at the Office of Religious Affairs to ensure that all were aware of
not just breastfeeding but of how the Qur’an and hadiths support it.
A separate team was established to oversee the creation of a fiqh booklet Islamic law booklet about breastfeeding from an
Islamic perspective. The team included members from all key stakeholders, both religious and health. The booklet would be
given to couples about to be married, as well as to Islamic scholars and preachers to use in their sermons and study
sessions. Formula Milk Ban: Puskesmas Beji, Tulungagung, East Java
As with many other districts in Indonesia, Tulungagung’s hospitals, puskesmas and private midwifery practices have
70
previously signed contracts to become distributors of formula milk. According to the head midwife of Puskesmas Beji, Ari
Murtiningtyas, this was because the health workers feel that they are making it easier for mothers to purchase formula milk,
because they do not have to go to a separate shop anymore. Fortunately, this attitude is now changing.
Puskesmas Beji decided to end their contract in May 2013 and ban the promotion and sale of formula milk throughout their
catchment area. To ensure this ban is implemented, village midwives undertake monitoring visits to private midwives to
ensure they are not selling formula milk, and house visits to educate families on breastfeeding.
Integrated Breastfeeding Campaign: Probolinggo, East Java The government of Probolinggo began its integrated
breastfeeding campaign by developing a district head regulation. This regulation gives a strong legal basis for breastfeeding
campaign activities; regulations like these are very important in Indonesia.
After the development of the regulation in mid-2013, the government carried out the following activities:
1. The District Head was elected as a breastfeeding
ambassador for 2013. 2.
A workshop for Islamic scholars and preachers on safe childbirth and immediate exclusive breastfeeding to
ensure religious leaders were in agreement with and supported the campaign.
3. Twenty-two sub-district Groups who Care about
Breastfeeding groups were formed.
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4. In November 2013, the District Head instructed health
facilities to plant katuk plants to support breastfeeding. 5.
In January 2014, the District Head instructed health facilities to plant kelor plants to improve maternal and
child nutrition. 6.
In March 2014, the government held a katuk and kelor food festival at which more than 200 different menu
items were cooked. 7.
A series of trainings for 60 traditional medicine sellers, vegetable sellers, and make-up artists were held to
encourage them to share information on safe delivery and breastfeeding with their customers and clients.
8. A training for health volunteers on how to better
support breastfeeding mothers was run. 9.
A training on breastfeeding was held for 49 breastfeeding counsellors.
10. In October 2014, 24 new breastfeeding ambassadors at
the sub-district level were elected. After being elected, the new ambassadors were trained on safe delivery and
immediate exclusive breastfeeding, and developed their work plans for the next 12 months.
A bridal make-up artist left who received training on how to discuss breastfeeding with brides-to-be.
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Our Community Cares about Breastfeeding: Makassar, South Sulawesi
The pro-breastfeeding movement in Makassar began in 2012 with a new district head regulation on exclusive breastfeeding.
This provided the legal framework for promotional activities on breastfeeding.
Kinerja supported the district to establish multi-stakeholder forums MSFs on health service delivery in its partner sub-
districts. The community took this idea one step further after realizing that there was a lack of men involved in maternal and
child health issues, and established a series of Fathers who Care about Breastfeeding groups. The MSFs and the Fathers groups
then worked together to develop the peer learning module for breastfeeding supporters.
Results and impact Co-operation between the Office of Religious Affairs and
puskesmas: Bener Meriah, Aceh Since incorporating safe delivery and breastfeeding information
into pre-marital courses, the rates of newly-wed couples carrying out immediate and exclusive breastfeeding have
increased. For example, during the first six months of the program that is, between June and December 2013, 13
couples took part in the course. Ten have since become pregnant, and eight of these have given birth. All eight chose to
do immediate breastfeeding, and were still breastfeeding their children at the time of writing. This means that there is a 100
success rate so far.
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From January to September 2014, 28 couples took part in the course. All have stated their commitment to carry out both
immediate and exclusive breastfeeding. Formula Milk Ban: Puskesmas Beji, Tulungagung, East Java
The impact of Puskesmas Beji’s formula ban is impressive. Within just two months of implementing the ban in May 2013,
the rate of breastfeeding in the puskesmas
’ catchment area increased from 55 to 88. Eight villages were already formula
milk-free within a month of the ban. It is clear that the increase was related to the ban, as rates of immediate breastfeeding
were already 100 at the puskesmas and there were no other promotional activities that went on at the time.
In addition, 80 of privately-practicing midwives have ceased promoting or selling formula milk at their clinics.
Integrated Breastfeeding Campaign: Probolinggo, East Java Immediate and exclusive breastfeeding have been proven to
improve a baby’s nutritional status. Although this link has not been explicitly studied in Probolinggo, the District Health
Office believes that better maternal nutrition and increased rates of immediate breastfeeding are part of the reason behind
a drop in the neonatal mortality rate NMR. In 2012, 230 babies died in Probolinggo; this fell to 201 in 2013, representing
a drop in the NMR from 12.43 deaths per 1,000 live births to 11.04 deaths per 1,000 live births.
Our Community Cares about Breastfeeding: Makassar, South Sulawesi
As a result of numerous promotional and awareness raising activities, exclusive breastfeeding rates increased significantly in
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Makassar between 2012 and 2014. At Kinerja’s three partner
puskesmas in the district, rates increased by more than 20 percentage points on average.
Rates of exclusive breastfeeding at Kinerja’s partner puskesmas in Makassar, South Sulawesi
2012 2014
Puskesmas Cenderawasih 58
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Puskesmas Batua 61
84
Puskesmas Patingalloang 48
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The overall average breastfeeding rate in Makassar also increased, reaching 67.8 in 2013, up from 61.35 in 2012.
The change in attitudes of mothers and fathers to breastfeeding has also been positive. Women are no longer embarrassed that
they breastfeed their child breastfeeding is seen as something that only poor women do in many parts of Indonesia; in fact,
now they are proud. Their husbands and families are also much more supportive of their choice to breastfeed than previously.
Monitoring and evaluation Co-operation between the Office of Religious Affairs and
puskesmas: Bener Meriah, Aceh The head midwife of each puskesmas monitors the rates of
immediate and exclusive breastfeeding at her own puskesmas and at the village-level birthing clinics. She also meets with new
mothers and mothers with young children to discuss their breastfeeding problems and successes, and to ask for feedback
on how the puskesmas can better support them.
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The staff of the Office of Religious Affairs work together with midwives from the puskesmas of Bener Meriah to examine the
impact of the program. They compare data to see whether couples have undertaken the pre-marital course and if they
then follow through with immediate and exclusive breastfeeding.
Formula Milk Ban: Puskesmas Beji, Tulungagung, East Java There is no formal system for monitoring the sale of formula
milk at facilities in the sub-district yet, but some informal monitoring has taken place. The head midwife regularly visits
the village-level birthing clinics and the private homes of midwives to ensure they are not selling formula milk and to
remind them to provide information on breastfeeding to all pregnant women and their families.
One unexpected result of this program has been that the quality of data recorded by the puskesmas and the village-level
birthing clinics has improved. Data is more regularly recorded than previously, and the clinic believes it is more accurate
because of this. Integrated Breastfeeding Campaign: Probolinggo, East Java
The monitoring of the breastfeeding campaign in Probolinggo has so far been limited to activities carried out by the multi-
stakeholder forums MSFs. The MSFs have developed monitoring tools to gather data on the rates of breastfeeding in
the district, and will use the data collected to make recommendations to the DHO.
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Our Community Cares about Breastfeeding: Makassar, South Sulawesi
The Fathers who Care about Breastfeeding groups have no external monitoring or evaluation. They monitor their own
activities, and solve problems collectively. They also take up more complex issues with the DHO and the puskesmas.
Challenges
The challenges experienced in each of the four districts profiled in this story are similar. Each faces continuing strong cultural
beliefs and misconceptions about breastfeeding, as well as the Indonesia-wide preference for formula milk because it is
thought to be healthier and more ‘modern’ than breastmilk. Even when mothers themselves understand the importance of
breastfeeding and wish to breastfeed their babies, they will frequently encounter resistance from their husband, mother, or
mother-in-law. Each district is working hard to slowly overcome these beliefs.
Other problems include the low level of understanding of midwives on immediate breastfeed and the proper way to
perform it; the lack of breastfeeding facilities in work places and public places; and the lack of desire among families to continue
breastfeeding after the first few months.
Sustainability
The sustainability of each of the pro-breastfeeding programs implemented in Kinerja’s four partner districts profiled here
relies heavily on community participation and support. Without the full involvement of the community, these programs will not
77
be successful and will not sustain themselves over the next few years. If the community continues to take part, however, as
they are currently doing, all four of these programs have a high chance of being sustainable.
Each program will also require support from the local governments, particularly from the District Health Offices. This
support must include financial support to ensure the programs are able to continue.
All of these programs have the potential to be replicated throughout the rest of Indonesia. Breastfeeding rates are low
across the country, and districts would do well to consider the programs presented here for implementation in their own
areas.
Lessons learned and recommendations - District head regulations are important. Regulations
such as those issue by the district head provide a legal basis for health workers to point to when they suggest to
community members that they exclusively breastfeed their babies. With the regulation in place, health workers report
feeling braver and more comfortable in giving breastfeeding advice to patients because they know the law and the
government supports what they are doing.
- Innovative campaign methods are key to building momentum. Formula milk promotion is so widespread
and so strong that it has reached even the most isolated villages in Indonesia. When families see on TV or read in
the newspaper that formula milk makes babies healthy and
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happy, they can be easily influenced to abandon breastfeeding. This means that creative and interesting
methods of promoting breastfeeding are necessary if the aim is to change behavior.
- Individual commitment is as important as organizational commitment. The role that individuals
can play is often overlooked. Kinerja’s experience in supporting districts to promote exclusive breastfeeding has
shown that key individuals, such as the District Head, can have a significant impact on behavior. That said, the
commitment of individuals at a smaller level is also crucial
– if a few midwives do not support exclusive breastfeeding
and continue to sell formula milk, for example, it is unlikely that their patients will change their behavior. Only when
individuals commit to change will the community follow.
- Data collection needs to be improved. One issue in
almost every district Kinerja supported was the lack of or poor quality of data on immediate and exclusive
breastfeeding. Data was often missing or incomplete, or had never been collected in the first place. When data did exist,
it had sometimes been collected through inappropriate methods and did not actually reflect the real situation. This
makes monitoring and evaluation incredibly difficult.
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Contact information
Bener Meriah Risnawati
Head of Puskesmas Bukit Jl. Mesjid Babussalam, Simpang Tiga Redelong, Kab. Bener
Meriah Puskesmas Beji, Tulungagung
Winny Isnaini Staff,
Lembaga Perlindungan
Anak Child
Protection Organsiation Tulungagung
wisnaini2003yahoo.com Probolinggo
Ana Maria Secretary, Probolinggo District Health Office
annamariadsymail.com Makassar
Siti Rohani Former staff, USAID Kinerja
sitirohani.mksgmail.com
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Partnerships between midwives and traditional birth attendants
help to improve maternal health in Aceh and South Sulawesi
Background
The Indonesian government worked hard in its bid to achieve the Millennium Development Goals MDGs, and especially
focused on Goal 5 Reducing Maternal Mortality. Indone sia’s
goal for reducing the maternal mortality rate MMR was a 75 reduction to 112 maternal deaths per 100,000 live births.
However, according to the 2012 Indonesian Health Demographic Survey IDHS, Indonesia was not on track to
meet this target. In fac
t, Indonesia’s MMR was increasing, and had jumped from 228 deaths per 100,000 live births in 2008 to
359100,000 in 2012. Based partly on this, the United Nations Population Fund UNFPA considers Indonesia to be one of the
world’s ten worst countries to be a pregnant woman. One of the reasons behind Indonesia’s continuing high MMR is
that many births are not assisted by trained medical professionals and do not occur in health facilities. This is
particularly the case in rural areas, where families often choose to use traditional birth attendants TBAs because they are
closer, cheaper, understand the local culture and religion, have spiritual knowledge, and are generally seen to be more
experienced than midwives. However, TBAs are not medically trained and many do not fully understand what is needed for a
safe birth to take place.
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Although they are medically trained, midwives are often considered to be too young and too inexperienced, in addition
to being too expensive and not familiar with local culture, religion, or language. Many midwives also do not live in the
villages where they have been assigned, and so are not always available. This perception further encourages local communities
to choose TBAs over midwives when a woman gives birth. To overcome this issue, the Indonesian Ministry of Health
established partnerships between midwives and TBAs more than two decades ago. Kinerja’s approach has been to make
these partnerships more desirable, more transparent, and more participatory. Two areas which had good success in doing so
were Aceh Singkil in Aceh Province, and Luwu in South Sulawesi Province. Both districts’ programs aimed to increase
the co-operation between midwives and TBAs, but took slightly different approaches and created different incentive schemes.
Aceh Singkil, Aceh Kinerja assisted Aceh Singkil to establish a midwife-TBA
partnership program in 2011. At the time, the district experienced a high number of maternal and neonatal deaths
– five women and 35 babies died in 2011. Overall, around 30 of
the district’s births were assisted by TBAs, 66 by midwives, and just 4 by doctors.
Aceh Singkil has a population of around 110,000 people, who live in mountainous regions, along river banks, by the ocean,
and on small islands. There are 122 active TBAs in the district and just 11 community health centers called puskesmas in
Indonesian, with only one that can take in-patients. Just two
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puskesmas are able to provide basic emergency obstetric and neonatal care BEmONC. There is one hospital, but it is not
yet capable of comprehensive emergency obstetric and neonatal care CEmONC.
Luwu, South Sulawesi Around 10 of deliveries in Luwu are assisted by TBAs. In
some rural areas, however, the rate is much higher up to 30. Around 330,000 people live in Luwu, which reaches from
the coast into the mountains. In 2012, the district recorded 15 maternal deaths, mostly due to post-partum haemorrhage and
eclampsia. 49 babies also died in 2012. Like Aceh Singkil, Luwu’s health facilities do not yet meet t
he communities’ needs – of the 21 puskesmas in the district, seven provide in-patient
Midwives and their TBA partners pose for a photograph in front of Puskesmas Singkil in Aceh Singkil.
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facilities and six can provide BEmONC services. There is no CEmONC-capable hospital.
Program Innovation
Although midwife-TBA partnerships have existed throughout Indonesia for some time, most are not well-implemented. The
approach needs some improvement – for example, it is
generally too top-down, does not properly take into account the interests of TBAs, does not provide strong enough
incentives for TBAs to participate, does not involve the community in design or implementation, and does not
incorporate enough monitoring and evaluation. Kinerja developed a new approach to implementing midwife-
TBA partnerships, based on key governance principles, as outlined below.
1.
Participation. Kinerja and its implementing organizations
IOs – usually local CSOs – involved a huge range of
stakeholders in developing, implementing and monitoring the midwife-TBA partnerships. They included community
members, village heads, government staff, puskesmas staff, village midwives, TBAs, and the media. Kinerja’s IOs also
helped establish multi-stakeholder forums MSFs made of community members and government representatives that
assisted in monitoring the program, incorporating community feedback, and developing memoranda of
understanding MOUs.
2.
Transparency. The development and signing of MOUs
between midwives and their TBA partners were done
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openly and involved all the different stakeholders. The MOU signing events were held in public places, and were
even sometimes attended by the Mayor or District Head as a witness. Details of the MOUs were then disseminated to
the public.
3.
Accountability. The content of the MOUs were agreed
upon by both midwives and TBAs before being signed, and points were altered if the parties did not agree. This
included information on financial incentives to be paid to the TBAs.
4.
Responsiveness. Key stakeholders such as puskesmas,
village heads and District Health Offices DHOs agreed to take action on any problems that may emerge during the
partnerships’ implementation.
Through these good governance principles, both midwives and TBAs can benefit from participating in the partnerships. As they
can now work together to assist women in childbirth, their workload becomes lighter and easier
– midwives are responsible for medical aspects, while TBAs are responsible for
spiritual aspects and for looking after the newborn. Aceh Singkil, Aceh
The District Health Office DHO of Aceh Singkil agreed to pilot Kinerja’s approach in two villages in 2012. After two
years, the number of births assisted by trained medical workers had increased two-fold, and the number of risky births had
decreased dramatically. The DHO decided to replicate the program to 29 other villages in four other sub-districts.
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Aceh Singkil’s approach to midwife-TBA partnerships is quite unique. As Kinerja was aware, one of the main problems in
implementing these partnerships in Indonesia has been the lack of strong financial incentives for TBAs. Without receiving some
form of compensation, the TBAs feel disrespected and as though midwives have taken away their only source of income.
To overcome this, the DHO of Aceh Singkil decided to pay decent incentives to TBAs agreeing to join the partnerships and
no longer assist births by themselves. Every month, each TBA receives Rp.100.000 US10 from the DHO and an additional
Rp.50.000 US5 from the village. For each birth she assists with her midwife partner at a health facility, she receives
another Rp.50.000 US5 from the puskesmas through the new National Insurance Scheme. The TBAs of Aceh Singkil
therefore feel appreciated and respected. By holding big events for the signing of MOUs between
midwives and TBAs, the level of commitment and enthusiasm for the partnerships was high. The TBAs and midwives both felt
as though they were now important players in the health status of their community, as they were being recognized at such a
formal event. Luwu, South Sulawesi
A different but also unique approach to developing midwife- TBA partnerships was also developed at one particular
puskesmas in Luwu, South Sulawesi. Puskesmas Bajo Barat is one to two hours away from the capital city, Belopa, which
means that local residents rely heavily on the puskesmas for healthcare. Fortunately, Puskesmas Bajo Barat offers in-patient
facilities.
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To encourage more women to give birth at the health facility with a midwife, Puskesmas Bajo Barat decided to increase the
costs patients must pay if they give birth at home but are still assisted by a midwife. Giving birth at the puskesmas costs
Rp.600.000 US60 but is reimbursed by the National Insurance Scheme JKN for patients who are members. Giving
birth with a midwife at home, however, now costs Rp.700.000 US70, of which JKN will only reimburse Rp.600.000, meaning
that the family must pay the gap of Rp.100.000. This strategy has been successful in encouraging more women to give birth
at the puskesmas and its village-level facilities, poskesdes. The TBAs of Bajo Barat also receive financial incentives to take
part in the partnerships. If they refer a woman in the early stages of labor to the health center, the TBAs will receive
between Rp.100.000 US10 and Rp.250.000 US25 for each referral. In late 2014, the local multi-stakeholder forum MSF
and the puskesmas advocated to the DHO to increase this fee. The DHO agreed to provide Rp.300.000 per referral from the
2015 budget. Midwives and TBAs in Bajo Barat hold yearly meetings to assess
the partnerships. Their MOUs are re-affirmed, successes are discussed, and any challenges or problems are solved or passed
onto the DHO for further action. If any midwives or TBAs are found to be disobeying the MOUs, they are sanctioned.
On top of this, Bajo Barat does its best to make sure its midwives are well-equipped and always available, so that
women are not scared of giving birth with them. Four midwives work at the puskesmas, and one midwife lives in each of the
sub-
district’s nine villages, working at the local poskesdes. The
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head midwife also makes sure that all of sub- district’s midwives
have complete midwife kits on them at all times. This is an impressive achievement, as only 39 out of 233 17 of
midwives in the whole of Luwu district had midwife kits in 2014. This helps reassure women that their midwives are well-
prepared to assist them in childbirth.
Implementation Process
The processes followed in Aceh Singkil and Luwu were very similar.
1.
Identification of problems
The first step was to identify problems and challenges relating to pregnancy and childbirth in the district. A meeting was held
and attended by puskesmas head and staff, midwives, village midwives, health volunteers, village heads, community figures,
religious figures, representatives of the Indonesian Midwives Association, youth representatives, the media, local NGOs,
members of the district’s Health Board, and government staff. The meeting identified the causes of low numbers of births
assisted by midwives, deciding that some of the reasons included low levels of public trust in newly-graduated midwives,
midwives’ lack of ability to speak local languages, midwives’ relative lack of experience, poor relationships between
midwives and the community, and the poor quality of staff and facilities at the district’s puskesmas and hospitals.
2.
Establishment of multi-stakeholder forums MSFs
MSFs were established at both the sub-district and district levels. At the sub-district level that is, at the puskesmas level,
the MSFs are responsible for advocacy, mediation, and
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monitoring and evaluation of health programs, including the midwife-TBA partnerships. The forums are made up of
community members, government staff, health volunteers, and others interested in quality healthcare.
3.
Informal co-ordination
Kinerja’s IOs worked closely with puskesmas and DHOs to overcome the problems identified in step one.
4.
Building a common understanding
Mini workshops were held to develop common understandings and goals as to what the midwife-TBA partnerships would
involve, including financial incentives. The agreement was written down in a draft MOU on Midwife-TBA Partnerships.
The workshops were attended by midwives, TBAs, the DHO, health workers, village heads, puskesmas, and religious figures.
5.
Village Head Decrees on incentives for TBAs
To formalize and guarantee the incentives to be provided to TBAs, the village heads signed and published Village Head
Decrees. 6.
MOU signing
After agreeing to all the conditions, the midwives and TBAs signed their MOUs at a public event witnessed by village heads,
puskesmas heads, heads of DHOs, representatives of the Indonesian Midwives Association, and the community. The
MOUs are to be renewed once every three years. 7.
Monitoring
Implementation of the partnerships are regularly monitored by MSFs. MSFs report their findings to the DHOs and puskesmas.
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Village midwives are also responsible for monitoring the partnerships, primarily to ensure that no TBAs continue to
assist deliveries by themselves. 8.
Replication
In Aceh Singkil, the program was replicated to an additional 29 villages in the first two years. In Luwu, the head of the DHO
issued a decree to replicate Kinerja’s approach at nine additional puskesmas, including the midwife-TBA partnerships.
Results and impact The level of trust between midwives and TBAs has
increased significantly since the beginning of the partnerships. Both midwives and TBAs acknowledge that the
MOUs make their rights, duties, and responsibilities clear, as well as making their everyday jobs easier and smoother,
because now there are two pairs of hands instead of just one pair. Midwives are happy that the TBAs can handle the spiritual
aspects of deliveries such as giving prayers, and TBAs are happy that midwives can deal with the medical aspects.
The heads of Kinerja’s partner puskesmas say that because of the midwife-TBA partnerships, midwives now know about
pregnancies earlier than before. This is because TBAs now refer newly-pregnant patients immediately to the midwives for
ante-natal care. Previously, this did not always happen. Through the partnerships, mothers can now access
professional health care in their local languages. Many village midwives do not speak local languages, but now they are
assisted by TBAs, who are generally from the local area. The
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TBAs thus act as a bridge between the community and the midwives.
Public events and discussions during the development process have
increased the community’s awareness of the importance of facility-based, midwife-assisted birth.
Aceh Singkil, Aceh A small but significant increase 6 has occurred in the
number of births occurring at the five sub-districts with Kinerja’s innovative midwife-TBA partnerships since they began
in 2011.
Births assisted by medical professionals in Kinerja’s five partner sub-districts in Aceh Singkil, 2011-2014
2011 1,476
2012 1,532
2013 1,509
2014 1,561
At Puskesmas Singkil, the pilot puskesmas for the program, the most impressive result is that the number of births assisted by
TBAs has fallen from 17 in 2011 when the program started to none in 2014. The biggest drop was within the first 12 months
of the program.
Births assisted by TBAs in Puskesmas Singkil’s catchment area, 2011-2014
2011 17
2012 8
2013 2
2014
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The co-operation between midwives and TBAs has also led to a higher rate of pregnant women seeking ante-natal care in their
first trimester. This has been a huge change for Aceh Singkil, as culturally, many women believe that if they speak aloud of a
pregnancy during the first three months, the baby will be susceptible to black magic or spirits. More than 200 more
women had a check-
up in their first trimester in Kinerja’s five partner sub-districts in 2014 as compared to 2011.
Number of pregnant women receiving an ante-natal check- up in their first trimester at Kinerja’s five partner sub-
districts in Aceh Singkil, 2011-2014 2011
1,525 2012
1,603 2013
1,649 2014
1,739
Aceh Singkil also entered its TBA-midwife partnership program into the 2015 United Nations Public Service Awards UNPSA.
It won second-place for the Asia-Pacific region – the first time
that Indonesia has ever won an award from UNPSA. The District Head and the Head of DHO attended the award
ceremony in Colombia and presented about the program, its implementation, and its benefits.
Luwu, South Sulawesi As with Aceh Singkil, Luwu also experienced an increase in the
number of births assisted by medical professionals in the three districts supported by Kinerja.
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Births assisted by medical professionals in Kinerja’s three partner sub-districts in Luwu, 2011-2014
2011 730
2012 782
2013 778
A small decrease occurred at Puskesmas Bajo Barat in 2013 due to the end of the clove and cacao farming seasons, when many
migrant workers returned to their home districts. The number of pregnant women seeking ante-natal care in
Kine
rja’s three partner sub-districts also increased.
Number of pregnant women receiving at least four ante- natal checkups in Kinerja’s three partner sub-districts in
Luwu, 2011-2014 2011
670 2012
766 2013
697
As noted above, a small decrease occurred at Puskesmas Bajo Barat in 2013 due to the end of the clove and cacao farming
seasons, when many migrant workers returned to their home districts.
Monitoring and evaluation
To ensure they have a good understanding of what is going on in their districts, puskesmas and DHOs run regular monitoring
activities in both Luwu and Aceh Singkil. Head midwives visit their village midwives every month to ensure they are following
the terms of the MOUs and to see how the program is progressing. The head midwives also collect monthly records of
patient services during these visits.
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In Aceh Singkil, the district’s Health Board also undertakes field visits to monitor developments. Members of the Health Board
meet with midwives and TBAs to discuss problems and successes, and they later share this information with and make
recommendations to the DHO. One example of how regular monitoring had a positive impact
in Aceh Singkil was the creation of an emergency contact card. When a monitoring team discovered that the residents wished
to be able to directly contact key persons in an emergency
– such as the village midwife, the head of the puskesmas, the head
midwife, or the DHO itself – they worked with the puskesmas
to develop a contact card. The card lists the mobile phone numbers of people who families might need to call if a mother
goes into labor and needs a midwife or ambulance. In Luwu, the multi-stakeholder forums established by Kinerja
regularly attend the puskesmas
’ monthly update meetings. At the meetings, they pass on community feedback and gather
information to share with community members.
Challenges
The main challenge in implementing an innovative, transparent and participatory midwife-TBA partnership program was the
resistance to cultural change. Both Aceh Singkil and Luwu are located far from major metropolises, for example, and remain
quite traditional in their cultural practices. Islam is also a major influence in both areas. TBAs are seen as having not just
medical knowledge but also cultural understanding and spiritual power, so it can be hard to convince mothers to give birth with
midwives instead of TBAs.
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Midwives’ low medical skills, a lack of local language ability, and a lack of understanding of local cultural beliefs was another
significant change. Patients were reluctant to give birth with midwives because they often could not communicate very well,
or dismissed their cultural beliefs without explanation. A lack of financial support for multi-stakeholder forums MSFs
limited their ability to carry out oversight and monitoring activities. Most MSF members are ordinary community
members, and do not have a lot of spare money to contribute.
Sustainability
Kinerja’s midwife-TBA partnerships are more likely to be sustainable than the previous top-down versions. This is
because they have taken into account the needs of both midwives and TBAs, as well as those of the community. The
partnerships are based on mutual co-operation and understanding, and seek to benefit both parties. This is key, as
previously many TBAs felt that their incomes were being taken away from them; now, they receive incentives for referring
patients to midwives, and are able to work together with the midwives to deliver babies in facilities.
The formalization of the relationships between midwives and TBAs was also crucial to their sustainability. By working
together to develop MOUs and by signing these agreements at a public event witnessed by senior government members, both
midwives and TBAs feel that their roles are important, respected and acknowledged. They are also able to refer back
to the MOUs if they have any doubts about their roles, rights
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and responsibilities. The MOUs also make clear any sanctions that may be implemented if the terms of the MOU are
breached. The publishing of decrees from the village heads and the heads of the DHOs also helps support this formalization
process, as these decrees are held in high regard by both government staff and community members. The program is also
more likely to be sustained because it fulfills not only the needs but the desires of mothers. Mothers in Luwu and Aceh Singkil
are very happy to be able to receive modern medical care from a midwife at the same time as getting spiritual care from a TBA.
Health outcomes are also likely to improve, as the midwife can look after the mother and the TBA can look after the newborn.
A TBA left and her midwife partner at an event in Jakarta celebrating Aceh Singkils second-place win at the 2015 United Nations Public Service Awards for its
TBA-midwife partnership program.
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Lessons learned and recommendations
The midwife-TBA partnerships in Aceh Singkil and Luwu only succeeded because of high levels of commitment from both the
community and the government. Without this strong co- operation, it is unlikely that the programs would have had a
significant impact. - Community participation is key to success.
Community members will have a hard time accepting and supporting new programs if they have not been actively
involved in all phases, from design through to implementation and monitoring.
- Stakeholders must trust each other. It is important
that the roles of all parties involved in a program are acknowledged and respected as actors of change.
- Appropriate incentives are required for behavior change. Incentives that are deemed sufficient by all parties
are necessary to garner support. It is important that the source, amount, and method of provision of incentives is
clearly defined in official documents such as MOUs, in addition to who is entitled to incentives and for what tasks
they will receive incentives.
- Regular and consistent communication makes implementation smoother. Regular supervision and
monitoring visits from head midwives to villages, for example, ensured the midwife-TBA partnerships remained
active and were well-implemented. Creative methods of encouraging communication are also useful, such as the
development of the emergency contact card in Aceh Singkil,
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which provided the contact details of key parties head midwife, village head, DHO, etc. to expecting mothers.
- Changing cultures and traditions is not easy.
Traditions are obviously well-embedded in communities, and require significant time and effort to change. To do so,
strategies and approaches that are culturally-relevant and appropriate to the local context must be developed and
used. The midwife-TBA program is a good example of this, as it combines the traditional health practice giving birth
with a TBA with the modern health practice giving birth with a medical professional, and offers patients the best of
both. This has meant that the community has been happy to alter their behaviors.
Contact information
Aceh Singkil, Aceh Edy Widodo
Head of Aceh Singkil District Health Office
edywidodo1967gmail.com +62 6581202
Luwu, South Sulawesi H. Abdul Aziz
Head of Service Provision, Luwu District Health Office +62 47121145
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Preventing child
marriage through
reproductive health
education for
teenagers in
Bondowoso, East Java
Background
Gender inequality remains a major challenge in Indonesia with regards to development. According to the United Nations
Development Program UNDP’s gender inequality survey, Indonesia ranked only 102 out of 148 countries in 2012. Just
36.2 of Indonesian women have a completed junior high school, for example.
Maternal mortality and teenage pregnancy occur significantly more frequently in Indonesia than in neighbouring Southeast
Asian and Pacific countries. It is estimated that 48 of every 1,000 live births in Indonesia in 2015 was to a teenage mother.
Teenage pregnancy is also one of the driving causes of maternal mortality, which remains incredibly high throughout the
archipelago, with 359 mothers dying for every 100,000 live births in 2014.
In recent years, the government of Indonesia has focused its efforts on reducing the number of maternal deaths. In 2014, the
national government launched a national action plan on how to reduce maternal mortality. The plan focused on improving
access to ante-natal care for all mothers, including teenagers. The issue of teenagers was seen as key to the success of the
plan, as child marriage remains common especially in rural areas
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where health access is more difficult. According to a 2013 report from SMERU, economic factors are the main factor
behind child marriages in Indonesia. Social and cultural forces are also influential.
Bondowoso, a district in East Java, is one district where child marriage is widely-practiced. In fact, Bondowoso ranks as the
district with the highest rate of child marriage in all of East Java, with more than 50.9 of marriages in 2011 involving children.
Unfortunately, child marriage is more common amongst underprivileged families because it is seen as a way of reducing
a family’s financial burden. Child marriage is also seen as a cultural tradition in
Bondowoso. In Javanese and Madurese culture, especially in rural areas, parents begin to worry about their children if they
are not married by the age of 15. Religion, specifically Islam, also contributes to high levels of
support for child marriage in Bondowoso. Many people believe that the best way of ensuring that children avoid pre-marital
sex, which is seen as a sin, is to get married young. This belief is complicated by low levels of knowledge about reproductive and
sexual health for adolescents. The information that early marriage can be physically dangerous for girls is not widely-
known, for example. Child marriage not only impacts a girl’s health but her welfare.
Many girls are forced to drop out of school when they get married. This leads to a cycle of poverty that is hard to break:
because she has only a basic education, she cannot get a well- paying job, and because she cannot get a well-paying job, she
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cannot pay for her children’s schooling and health needs. This is reflected in Bondowoso’s continually low Human Development
Index HDI, which is the second lowest of all 38 districts in East Java.
Program Innovation
In order to begin solving the problem of high maternal mortality and high rates of child marriage, the government of
Bondowoso worked with Kinerja and its implementing organizations IOs to develop a reproductive health program
for students, parents, and broader society. The main objective of the program is to increase awareness of the importance of
reproductive health education for teenagers, to reduce the frequency of child marriage, and to reduce the maternal and
neonatal mortality rates.
A Bondowoso teenager and her artwork encouraging other teenagers to learn about reproductive health, avoid casual sex, and delay marriage.
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In 2012, the government of Bondowoso worked with the Indonesian Family Planning Association PKBI
– Perkumpulan Keluarga Berencana Indonesia to conduct a baseline survey on
maternal and neonatal death in the district. Following the baseline, a community forum known as the multi-
stakeholder forum MSF was developed, made up of community members who care about maternal and child health.
The MSF advocated to the government to give extra attention to youth reproductive health, following which the District Head
developed a decree covering safe delivery, immediate exclusive breastfeeding, and youth reproductive health.
The District Head also issued an instruction letter which identified a number of community figures, including his own
wife, who would become Reproductive Health Ambassadors. The District Head’s wife was elected as the lead ambassador
and was given the title of ‘Mother of Reproductive Health’. She became very active in promoting youth reproductive health,
and has taken part in many activities since assuming her role. Religious figures, both male and female, play an influential role
with regards to child marriage in Bondowoso. The community strongly respects religious figures, and frequently consults them
on important issues. In order to ensure they give accurate and relevant advice on child marriage, the Bondowoso District
Health Office DHO worked with religious figures and provided them with training on maternal and child health.
Following the trainings, religious figures who attended were able to provide information on the physical and mental risks of
child marriage and pregnancy. Religious figures in Bondowoso
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are now strong supports for the district government’s youth reproductive health program.
The DHO worked with a national NGO, the Women’s Health Foundation YKP
– Yayasan Kesehatan Perempuan, to carry out awareness raising activities and trainings on youth
reproductive health at schools in Bondowoso. These activities involved both students and teachers, and led to the formation
of a number of community groups. One of these is the Union of Teachers who Care about Reproductive Health, which was
founded by a number of teachers who were concerned about the high rate of girls who dropped out of school following
getting married andor pregnant. The teachers in the group began including reproductive health information in the annual
orientation sessions for new junior and senior high school students and during biology classes. The teachers worked
together with community leaders and members of the Family Welfare Movement PKK
– Pembinaan Kesejahteraan Keluarga to share reproductive health information with young people
and their parents to ensure that all are aware of the risks associated with child marriage.
The students themselves also formed a community group and a peer-learning program. The group, called the Blue Sky
Community Komunitas Langit Biru, worked with a local NGO, Hometown Kampung Halaman, to use media to raise
young peoples’ awareness of their reproductive health. This activity has been strongly supported by the DHO, as they
recognize the fact that young people are more likely to listen to their friends and peers. The group meets every two weeks, and
runs regular awareness raising activities. A peer-learning program was established in four sub-districts, and has since
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been expanded to a total of 25 sub-districts. From reaching just 24 students in the program’s first year, by 2015 the peer-
learning program has trained 279 students in reproductive health issues.
Together, all these activities have contributed to a significant decrease in the rate of child marriage in Bondowoso. In 2011,
51 of all marriages in Bondowoso involved children under the age of 18; in 2012, the percentage fell to 50, and in 2013, it
fell again to 43 - a huge drop of seven percentage points, or 14 of total marriages, in just one year. Such a large
improvement has never before been recorded in Bondowoso.
Implementation Process
Kinerja and the government of Bondowoso jointly decided that a program focused around youth education and empowerment
as likely to be the most effective way of reducing rates of child marriage. If children can be reached while they are still
teenagers, they are more open to learning different ideas. This is important, because in 2011, 51 of marriages in Bondowoso
involved children. Research from PKBI also showed that 52 of women with children under the age of 12 never graduated from
primary school, meaning that early intervention is crucial to reversing child marriage rates.
Based on PKBI’s research and advocacy from the district’s MSFs, the District Head of Bondowoso issued a District Head
Regulation in 2012 on safe delivery and exclusive immediate breastfeeding. The regulation also covers reproductive health
education for young people. The District Head also appointed his wife as the ‘Mother of Reproductive Health’ and the wives
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of village and sub-district heads as reproductive health ambassadors, tasked with supporting youth reproductive health
education in their respective areas. The women elected as reproductive health ambassadors
involved young people in their outreach work by including them on monitoring visits to villages. The women aimed to
investigate whether there were any families planning on marrying off their young daughters. If such cases were
identified, the ambassadors and young people provided the family with information on the risks of child marriage and the
benefits of delaying marriage. The families were encouraged to let their daughters finish school before marrying.
To expand the reach of the program, the District Head and the District Health Office decided to involve all layers of society,
including religious figures, community figures, teachers, health workers, NGO workers, women’s groups, and youths. These
representatives were chosen as program implementers because they are the people who interact directly with youths every
day. Everyone involved plays a slightly different role based on their
usual tasks and responsibilities. For example, the DHO and partner NGOs carry out reproductive health education for
teenagers, teachers, health workers, and religious figures. Other community members became involved in different ways,
e.g. 50 religious teachers took part in a competition and developed
special seven-minute
sermons on
youth reproductive health and the importance of delaying marriage.
After the competition, the religious teachers took their new
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knowledge back to their mosques and began incorporating the material into their other work.
One unique element of the program is the incorporation of youth reproductive health into orientation week for all new
junior and senior high school students. Previously, new students never received this sort of information during their
orientation period. School teachers were also taught how to add reproductive
health knowledge into their existing classes. Teachers involved in the Teachers who Care about Reproductive Health group
also visited every sub-district in Bondowoso to reach out to local officials and parents to improve their knowledge of youth
reproductive health and child marriage.
Bondowoso students learn from their peers about reproductive health and child marriage.
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Community awareness raising on the dangers of child marriage was carried out through a range of different events, such as
trainings, festivals, and competitions. One of the most successful events was the ‘My Health, My Future’ competition.
Local teenagers wrote articles, made short films, and designed promotional posters on youth reproductive health. The festival
was held at the District Head’s office and was attended by around 400 students from 27 junior and senior high schools.
More than 300 students registered for filmmaking training sessions, despite only 50 places being available. The students
learnt to make short films, some of which are now available on YouTube, such as ‘Tak Mau Seperti Ibu’ ‘I Don’t Want to
Beco
me Like Mum’, a film about a woman who married when she was just 12 years old. The film aims to encourage young
girls to stay in school and delay marriage. Awareness raising was also carried out through radio talk
shows. A number of Bondowoso radio stations regularly allocated time to talk about reproductive health and child
marriage, especially on Saturdays when many young people tend to listen to the radio. The radio shows also gave teenagers
the opportunity to call or SMS questions to have them answered on air.
Results and impact
Many useful outputs emerged from the youth reproductive health program in Bondowoso, including:
a. The District Head Regulation on Safe Delivery and
Immediate Exclusive Breastfeeding. b.
Two District Head Decrees on reproductive health ambassadors, which encouraged the wives of village and
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sub-district heads to support youth reproductive health. At the time of writing, 219 wives of sub-district heads and 23
wives of village heads had agreed to become reproductive health ambassadors in their areas. The position of
reproductive health ambassador is now respected in Bondowoso and recognized as a source of accurate
information and knowledge.
c. Peer educators, who were trained and educated on
reproductive health and child marriage. Peer educators came from all age groups, not just teenagers but also
parents, teachers, and other community members.
d. The inclusion of reproductive health information into
orientation week material for new junior and senior high school students.
e. The establishment of the Teachers who Care about
Reproductive Health group. The group has so far undertaken a roadshow to sub-district and village heads in
Bondowoso to spread the message of how child marriage endangers young women.
f. The founding of the Blue Sky Community. The teenagers
involved in this group target other youths and aim to improve their understanding of their reproductive health
and rights. The Community has already printed articles in local newspapers, made short films, and participated in
radio talk shows.
The outcomes of Bondowoso’s program to delay child marriage have also been positive:
a. The percentage of marriages in Bondowoso involving
children under the age of 18 fell by 14 in just two years. In 2011, 51 of all marriages involved children, and in 2012,
this remained high, at 50. However, by 2013, this rate had
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fallen to 43 - a drop of seven percentage points in just one year. This is a great success.
b. Anecdotal evidence indicates that more young girls are
staying in school and delaying marriage. This means they are able to earn a better salary and do not need to get married
for purely economic reasons.
c. Young girls are better-supported to make decisions for
themselves based on fact, rather than being pushed by family members to make hasty choices.
d. Girls are empowered to protect their reproductive health
and control their own fertility. By taking part in youth reproductive health education programs, girls receive
information that they otherwise miss out on, meaning that they will be healthier throughout their whole lives.
e. The risk of maternal and neonatal mortality and morbidity
decreases as women know more about their own body, health, and rights. Young girls have been shown to be at
significantly increased risk of death as a result of pregnancy and childbirth because their bodies are not yet physically
ready; by delaying marriage and childbearing, girls are more likely to have safe and healthy pregnancies and children.
f. The Human Development Index HDI has improved in
Bondowoso in line with reduced child marriage rates. In 2011, it was 63.81, and by 2013, had risen to 65.42.
g. Traditional beliefs are slowly disappearing. Reproductive
health is no longer seen as a taboo topic in Bondowoso, and is now discussed openly by all. The stigma surrounding
unmarried girls over the age of 15 has also begun to decrease, primarily thanks to the strong involvement of
religious teachers and community leaders in the district’s anti-child marriage campaign.
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Monitoring and evaluation
The government of Bondowoso primarily monitors changes in attitudes towards child marriage by analyzing marriage statistics.
The DHO collects annual data on youth reproductive health, and compares its own data and data from other government
bodies with the information collected by PKBI in 2011. This helps the DHO see trends and year-on-year changes.
Informal monitoring is carried out by groups and individuals such as the reproductive health ambassadors and peer
educators, who monitor occurrences of child marriage and attempt to discourage families from marrying off their young
daughters. Many community members are now also paying careful attention to local gossip and rumours, and if they hear
of any upcoming child marriages, they contact a reproductive health ambassador, who visits the family in question. All of this
information is generally passed on to the district government for recording.
Challenges
This program aims to change old ways of thinking and traditional beliefs on child marriage in Bondowoso. It is not
surprising, then, that the major challenge has been cultural, particularly in terms of overcoming the genuine belief that girls
who are not married by the age of 15 will face problems finding a husband.
Child marriage is also seen by many Bondowoso residents as a way of ensuring young people are not sexually active before
marriage. Pre-marital sex is a major taboo in the district, and is generally seen as something that should be avoided at all costs.
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However, this mindset is problematic, because it means that even talking about sex is taboo, which results in young people
not being given the reproductive health information they need. Economically, it has also been hard to change parents’ ways of
thinking. Marrying off a teenage daughter is often seen as a solution to financial challenges, as it means that there is one
less family member to feed. These cultural and economic challenges will inevitably take
many years to overcome. The situation is made even more difficult because of low levels of education
– the average resident of Bondowoso has just 5.94 years of schooling.
The district government and local NGOs are attempting to solve this issue by making broad public participation a central
element of their programs, targeting not just children but also their parents and key community figures.
Sustainability
The issuance of a District Head Regulation and two decrees relating to youth reproductive health and child marriage mean
that the legal basis exists for continued focus on these topics. This is very important as it illustrates to the community that
the government and its elected head supports change. The inclusion of reproductive health information in school
subjects and the orientation period for new students is an excellent development, and will be crucial moving forward. It
will ensure that all students are reached with information on the importance of knowing their bodies and delaying marriage.
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The government has committed to continue the reproductive health-inclusive orientation program into the future.
The fact that both men and women and boys and girls are actively involved in the program greatly supports its chances of
sustainability. The involvement of male religious figures is particularly exceptional as, unfortunately, Islamic figures
throughout
Indonesia frequently
provide incomplete
reproductive health information. The district head’s wife and women’s groups have been excellent role models in promoting
youth reproductive health and the risks of child marriage to local residents, especially women and girls in marginalized
communities. Most importantly, teenagers themselves have been involved in the program with a leading role as educators
and role models for their peers through art and the media, as well as through the election of youth ambassadors
– a highly- coveted position. Local teens are now encouraged to speak
publicly about youth reproductive health. This ensures that the topics of reproductive health and child marriage will not
disappear from sight.
Lessons learned and recommendations
The key to the success of the reproductive health program in Bondowoso lies in co-operation. The program was and
continues to be implemented by a wide range of partners: Kinerja USAID, a number of local NGOs, the Bondowoso
District government, the Bondowoso District Head and his wife, village and sub-district governments, health workers,
teachers, the media both mass media and citizen journalists, religious figures, and community figures. This proves that even
when attempting to change long-held cultural beliefs, change is
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possible through working together in a genuinely participatory way.
One crucial lesson is the role that can be played by religious figures. In Bondowoso, religious figures are hugely respected
and listened to. When they began advising against child marriage, the impact was immediately noticeable, with the rate
of child marriage dramatically falling from 50 to 44 in just one year 2012 to 2013.
As child marriage most severely affects the lives of children, it is clear that children themselves should be involved as not just
recipients but as leaders. By educating young people on reproductive health, they are able to become peer educators
Two teenagers film a video about child marriage in Bondowoso.
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and share their knowledge with their friends and schoolmates. This is a very effective manner of changing young people’s
attitudes, because they are more likely to listen to and believe their friends than their teachers or parents. The young people
of Bondowoso were offered the chance to become reproductive health ambassadors, make their own anti-child
marriage films and posters, and form community groups. Overall, changing long-held community beliefs cannot be done
from above, led solely by the government. Bondowoso’s experience in successfully reducing child marriage rates
supports this theory. Their active involvement of all sectors of society
– from teachers and health workers to religious figures and the wives of government officials
– shows that change is possible when all are genuinely involved and understand the
reasons why change is necessary.
Contact details
Dr. Titik Erna Erawati Head of Family Health Section, Bondowoso District Health
Office
titikernaerawatiyahoo.com
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Community Participation
in Health
Minimum Service
Standards Planning in Jayapura, Papua
Background
Between 2009 and 2013, the budget allocated to public health services in Jayapura District dramatically decreased. While in
2009 the health budget represented 11 per cent of the government’s total budget, by 2013 it had fallen to just 5 per
cent. The
local government’s supposed commitment to health was not reflected in this allocation, and the district was not able
to meet its Minimum Service Standards MSS targets as mandated by the national government. In 2013, Jayapura only
achieved 36 of its MSS targets.
A medical worker inspects the teeth of a patient in Jayapura.
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Although MSS became a national requirement in 2008 through the Minister of Health Regulation No. 741 Menkes PerVII
2008, many health office staff do not understand the regulation and do not consider MSS important. Consequently, MSS is not
used as a reference for developing new health programs; furthermore, it is not used to evaluate the government’s
performance. In addition, the government of Jayapura does not involve
community members in the development of health policies and programs. Many community members also do not understand
their rights to quality health services, so demand for improvements is low.
Innovation
The low quality of health services in Jayapura is mainly caused by poor funding, inadequate understanding of MSS, and the
absence of community participation. In order to improve Jayapura’s health services, Kinerja not only works with the
government but with the community, building the capacity of local organizations to raise public awareness on people’s rights.
Once the people understand their rights, they can demand quality public services.
Recognizing that genuine partnerships between the government and the community are the key to implementing good
governance in the public sector, Kinerja works closely with Jayapura District H
ealth Office DEO. With Kinerja’s assistance, DEO staff improve their understanding of MSS and
are able to apply the standards in their efforts to provide quality health services. Kinerja’s assistance in Jayapura covers
three main stages: i identifying MSS achievements, ii
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identifying gaps, and iii estimating the costs and developing scenarios to close gaps and meet targets through new policies
and programs. In brief, Kinerja’s MSS program is carried out in the context of
citizens’ health rights. Both government staff and community members are expected to understand that the government is
responsible for providing standardized health services for the people and it has to prioritize it.
Implementation Process
Health service improvement programs are implemented by district technical team, whose membership consists of the
decision makers from different relevant offices. The team advocates to the district administration to involve community
District health office staff identify problems in health services at a workshop.
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members in the process of integrating MSS in health into district planning and budgeting.
Program implementation began with capacity building for local government staff, which was conducted through the following
steps: 1.
Raising awareness of relevant stakeholders decision makers, policy implementers, and community members on
MSS in the health sector. 2.
Reviewing and updating policies as needed. 3.
Collecting data that would be used for calculating MSS achievements.
4. Analysing gaps.
5. Estimating budget and resources that are needed to close
the gaps ‘costing’. 6.
Public consultancy and oversight. 7.
Integrating MSS targets and costs needed to achieve them into district health office’s and local government’s plans and
budget. 8.
Budget advocacy to decision makers to ensure the budget is signed off on.
9. Evaluating MSS achievements and collecting input for the
next planning process. In Jayapura, public consultancy was carried out to discuss MSS
costing results with broader stakeholders. The consultancy involved technical offices and other governing bodies since MSS
achievements required inter-sectoral co-operation. The consultancy also provided room for community members to
give their feedback and to support the district health office when it implemented the programs.
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The Kinerja-supported multi-stakeholder forum MSF, as a community forum, was committed to monitoring health MSS
achievements. MSS-related issues are discussed at MSF meetings both at the district and sub-district level so that
citizens can better understand the issue. In addition, a number of radio talk shows on MSS have been carried out by local radio
stations, Radio Kenambai Umbai and Radio Suara Kasih. These outdoor and indoor talk shows help to create momentum on
standardized health service delivery. A citizen journalist forum called CYCLOPS and a forum of citizen documentary video
makers, HILOI, also cover issues about standardized health services.
Results and Impact
Jayapura District has calculated the
resources needed
to achieve health MSS targets for
four years – 2014 to 2017. The
budget needed in 2014 was IDR 6,271,382,000
approximately US475,000,
and it
will increase to IDR 14,232,772,161
approximately US1 million for 2017. The budget increase is
based on how to achieve the annual increases in targets. The
Jayapura
administration is
committed to providing funds for to achieve MSS in the health
sector in coming years.
MSFs encourage governments to implement good
governance. Government works with people to identify
problems that health clinics face, discuss and address them.
People should share responsibilities and have good
understanding on how to be healthy.
-Amos Soumilena MSF Coordinator, Jayapura.
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Kinerja’s MSS program has successfully improved the awareness of government staff and community members on the
importance and usefulness of MSS. It has also increased government staf
f’s skills in assessing MSS achievements, estimating costs needed to achieve targets, and integrating
standards into work plans and budgets. In 2014, the District Health Office allocated IDR 6.69 billion approximately
US500,000 to fund programs to achieve MSS targets. The relationship between the District Health Office, the
community health centers and the community is much stronger than it used to be. Both the government and the health centers
involve MSFs as community representatives in their program planning and monitoring meetings. Being involved in the
government program development, community members trust the local government more, and are more willing to support
and to contribute to program implementation. For example, Kampung Yoboi in Sentani used village funds to
provide financial support for four tuberculosis TB volunteers, who conduct TB education and observe treatment compliance.
Previously, the volunteers only received a very small stipend form the health centers. Also in Sentani, an MSF called Forum
Dobonsolo
successfully advocated
the sub-district
administration to build TB posts in seven villages using Village Economic Empowerment funds.
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A pregnant women undergoes a prenatal he k i o e of Ki erja’s part er li i s.
With improved skills of MSS achievement analysis, health clinic staff are able to provide standardized health services.
Monitoring and Evaluation
With Kinerja’s help, the Jayapura District Health Office evaluated MSS implementation results in 2014 by involving
MSFs. During the evaluation, government staff and community members assessed activity status, results, and challenges. This
collaborative monitoring and evaluation will be conducted annually. If the activities are under target, the government and
community seek solutions through broad consultation.
Challenges
The biggest challenge relating to implementing the MSS program in Jayapura was to maintain stakeholders’ commitment
and develop appropriate skills. This problem was addressed through advocacy both formal and informal, workshops and
meetings, especially with senior and mid-level staff.
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Sustainability
MSS program sustainability is highly reliant on the commitment of the head of the district health office. Based on Kinerja’s
experiences, the head will commit to sustaining MSS if they have evidence about the program success. In Jayapura, Kinerja
believes the MSS program is likely to be sustained since the costing results, including indicators of the MSS targets, and
activities to achieve the MSS have been integrated into the five- year strategic plans of the district health office, as well as annual
plans since 2014.
Lessons Learned and Recommendations
The lessons learnt from the benefits of community involvement in MSS include:
1. Awareness raising is vital for both service providers and
service users. It means that people are able to give meaningful feedback to health service providers because
they have been involved since the program’s inception and are aware of targets.
2. Programs that are based on the local context lead to
increased levels of support. The MSS program in Jayapura not only took into account local values and
beliefs, but was clearly based on local needs and evidence. This resulted in genuine support for the
program from both government staff and community members, as they were able to understand why MSS is
important for health services in their district.
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3. Mainstream media, citizen journalism, and community
forums such as MSFs can be powerful agents of change. Their position allows them to disseminate MSS-related
information and to improve people’s knowledge on how MSS helps to fulfill their rights. In addition, partnerships
of government, media, MSFs, health centers, and the district health office create joint opportunities for
stakeholders to mobilize local government and community resources.
4. Implementing MSS in the health sector has led to a good
appreciation for accurate data. Government decision makers are now aware that data is needed to develop
strong work plans, create targets, and assess achievements. Learning about MSS has helped them to
do this. Now, having seen benefits of MSS, the Jayapura district administration plans to adopt the program in
other government technical offices.
A number of recommendations can also be made on how to better incorporate MSS into health sector planning, budgeting,
and monitoring:
a.
Community members should be involved in the full program cycle activity and budget planning,
costing, MSS integration into budgets and planning, implementation, and monitoring and
evaluation. Public participation is essential to ensuring that health services are delivered in line with MSS and
that people’s rights to health services are fulfilled. Community participation is vital in all areas, including
areas with high levels of political and social tension.
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b.
Intensive mentoring on MSS implementation, including for community members, should be
continued to ensure local governments and health centers deliver services in line with national standards. It
should be noted that Law no. 252009 confirms that people have the right to oversee public services. Their
ability to do so must be strengthened. There are two important activities to ensure citizens are able to
oversee service delivery i establishment of community forums, and 2 transparent information among local
governments, community members, district health office, and health clinics.